Transcript of "Innovation and the Health Care Needs of Seniors"
An assessment of how the changing landscape of care coordination and
providers are centering on collaboration and care in the home.
THIS IS THE FIRST IN A SERIES ON CHRONIC ILLNESS.
Innovation & the Health
Care Needs of Seniors
Our society is confronting a major dilemma around health care for older Americans. Fortunately, the
healthcare landscape is seeing a range of innovative approaches to positively impact this situation.
Four significant challenges are discernible as we consider the health and care of older Americans:
The prevalence of chronic illness – a natural accompaniment to aging and something that expands
as improved treatment of medical problems begets chronic conditions in need of on-going
The availability of adequate numbers of care professionals – those who actually deliver care and
support to individuals – for the growing “in need” population.
The huge cost of our healthcare system itself – including the cost of support and medical
interventions, the tools and technologies applied to those efforts, and the administrative
infrastructure and its associated bureaucracy.
The human desire to live longer at virtually any price (and frequently in the face of certain personal
discomfort, emotional suffering and minimal or no chance for reversal or significant life extension),
which underpins a broad-based, consumptive societal view about resource use – no matter how
limited, unproven or expensive.
A wonderful outcome of our society’s focus on health – and the great advances in technical interventions
led by American medical science and the industry it supports – is that we are living longer. Yet much of
the illness that accompanies aging is treatable and tolerable rather than curable, and as a consequence
we are aging with an increasing burden of chronic illness. Indeed, 80 percent of seniors (defined as
those 65 years or older) live with at least one chronic illness, and as our age increases the number of
such co-morbidities increases, with the average 75 year-old suffering from three chronic conditions.
Referencing a comprehensive report on aging and health,
The New England Journal of Medicine noted that the average
Medicare recipient sees seven different physicians in a
given year and takes five prescription drugs. And within
the medical community, sub-optimal care delivery is an
inevitable result given the general lack of communication
between care providers (we note that nationally, a common
or shared health record for each individual does not exist,
and an electronic health record, with some potential for
shared access if designed for that end, is used by less than
20 percent of physicians today). Efforts to correct this are
underway, but it is fair to say that compelling solutions, with
high levels of acceptance within the medical community
and resulting obvious gains in care improvement and cost
reduction, are years away.
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Complexity of care, another outgrowth of multiple medical conditions afflicting an individual, adds to the problem. As
the number of chronic conditions increase, so too do the number of specialists and care providers involved in the
care plan (this is especially prevalent in a healthcare system with a bias towards specialist care as the foundation
for the system). Additional consequences of an uncoordinated system such as unnecessary and/or redundant
testing and duplicate or competing prescriptions are then added to the overall challenges of dealing with complex
and chronic conditions.
The end result? Resource consumption, missed interventions, poorer health and spiraling costs – particularly for
those individuals who are the most sick and vulnerable. But in the end, all share the huge and persistent burden –
both in social as well as economic terms.
Barriers to Change and Innovation
Despite the obvious challenges and the innovative responses to them (many of which are technolgy-based), the
adoption of new approaches to care has been slow. The barriers to change are meaningful, led by factors such as:
Slow adoption: Despite the potential value in technology solutions, seniors are traditionally slower than average
adopters of technology. Less than half of all seniors over the age of 65 are online, and although about 90 percent
of Americans ages 18 to 49 own cell phones, they are owned by only 57 percent of seniors 65 and older. One
significant underlying reason for this is that most products are not designed with seniors in mind.
Physician resistance: While studies show a positive link between patient health and technology adoption by
physicians, doctors are far too often reluctant to change how they approach caring for their patients (distinct from
the frequently quick use of newly introduced and marketed therapies, prescription drugs and medical equipment
and devices). Further, a lack of Medicare and personal health insurance reimbursement for many new care
delivery approaches for those without face-to-face interaction between doctor and patient among them – is a
contributing factor. Economic incentives to engage all parties must be applied when striving for progressive
change in our healthcare system.
Out-of-pocket costs: A recent study from PriceWaterhouseCooper revealed that of the U.S. consumers willing
to buy a remote monitoring device, 64 percent would only do so if it cost less than $50; and they would only use
a mobile phone service to manage their health if it cost less than $5 per month! The costs of most devices far
exceed this threshold, although representing a fraction of the costs for more traditional approaches to care.
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Reimbursement issues and lack of defined sales channels: Virtually all of the potentially relevant
products have yet to meaningfully gain a presence in the senior market. This is at least partially a
result of (1) the lack of third party reimbursement; and (2) relatively low levels of direct-to-consumer
marketing in these areas to date.
Regulation: The FDA has indicated that it intends to regulate the flow of health information, and there is
significant confusion around what this means. This creates legitimate concerns with those developing
health information products, and fosters ambivalence among those who might use them. Neither is
good news for the prospects of adopting services that many view as positive change.
Products instead of solutions: A key issue is that there are now dozens – if not hundreds – of
technology products for the elderly and their caregivers, but they lack integration with each other in
ways that will truly facilitate solutions to meaningful health and well-being challenges (rather than
responding to single or occasional potential “events”).
It is obvious that the challenges that inhibit or delay change are significant, but the opportunity to improve
how we care for and support our aging population is real and of immense importance. Despite the barriers
and shortcomings in our approaches to date, this challenge is being addressed through a considerable
number of innovative efforts to bring real solutions to the support of older Americans.
The enclosed report “Innovation & the Health Care Needs of Seniors” provides a foundation for considering
the issues. It will be followed by a second installment addressing issues of equal importance, such
as financial planning considerations and care for caregivers. We trust you will find these publications
informative and useful.
– TripleTree Research
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In 2011, the first wave of the baby boomers will turn 65; by 2030, it is projected that there will be 72 million elderly
Americans – more than double the number in 2000. This startling demographic change has tremendous implications
for our society, ranging from the availability and utilization of our healthcare resources and economic costs to the
fundamental mores that shape our lives. Despite the importance of these issues, we are ill prepared to address these
challenges, and with each day seeing another 10,000 people turn 65 years old, the situation is steadily becoming more
Individual health, and with it the cost of ensuring that health, is at the center of this challenge. Unfortunately, the
current healthcare system lacks much of the infrastructure to support the complex needs of our aging population.
The costs associated with our current approach to care delivery are driving innovation and may occur as incremental
change or more aggressive moves. Such steps must be based on the understanding of needs and practical ways to
The issues surrounding the health and well-being of older individuals will be met by a variety of business responses,
many of them highly innovative and bringing forth solutions from non-health care disciplines. Regardless of their
individual specifics, they will likely be representative of, or responsive to, one of a half dozen major trends:
Care providers will increasingly be organized into more cohesive, interactive and provider-centric organizations
designed to address the entire spectrum of health needs.
Reimbursement for services will slowly, but progressively, shift from “pay-for-doing something” to a more global,
fully inclusive fee that encompasses the entirety of care for the individual.
Vehicles to enhance well-being and prevent illness will be increasingly important and in demand.
Technology will play an increasingly important role in the management, delivery and assessment of medical
care. Relevant services will deal with administrative support, data collection, information sharing, remote illness
assessment and monitoring, and personal education.
Seniors, spurred by both economic realities and personal preference, will seek to remain in their own homes, even
when confronted with illness and disability.
Health and wellness interventions will progressively move to where people live, thus providing a more consumerresponsive approach to care and illness prevention.
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This report will discuss current and emerging efforts that address the needs of this important demographic group –
seniors – by considering products, services and approaches intended to meet their particular needs and circumstances.
The parties attempting to meet these challenges are many and share a vested interest in success. They include the
Federal and state governments, public companies, both for-profit and not-for-profit private entities, special interest
support groups, families and individuals themselves.
The majority of new efforts in this arena are technology-based or enabled, a fact that should make the prospects for
greater efficiency, and in turn lower cost, an expected outcome. It is also worth noting that while this report focuses
on the age band of 65 years and older, much of what is discussed is applicable to those individuals 50 years of age
or more who are striving to enjoy the second half of their lives. This translates into an even larger population and
“market” – to say nothing of the breadth of need – than that defined by the moniker ‘seniors.’
The scope of these efforts are immense, as are the number of parties involved. Recognizing this, and while
acknowledging the vast number of efforts being made in this arena by public entities and not-for-profit organizations,
the focus herein will be largely on private companies who are responding in new ways to the various needs of older
Americans. This report will in particular focus on the delivery of care itself; efforts to facilitate safe and healthy
personal living situations; and various benefit coverage, personal finance and decision-making processes.
In so doing, it is hoped that insights into a number of new approaches and innovations will benefit the advancement of
the health and well-being of seniors and older individuals throughout this country.
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CHANGING THE DELIVERY OF MEDICAL CARE TO SENIORS –
WHERE, HOW AND WHY:
Innovative vendors are advancing new, improved ways of preventing and treating illness among seniors, as well as
better ways to support their day-to-day living.
As these enlightened approaches to advance health and well-being are developed, it is inevitable that they be
implemented in terms of where seniors live, how and by whom they are supported, which vehicles and approaches are
used to meet their medical care needs, and how we organize to support them.
Where We Live
The dramatic shift in our country’s demographic profile has been the source of endless debate regarding the
appropriateness and sustainability of our current care delivery infrastructure. A parallel discussion centers on
approaches and resources for housing the growing population of older Americans. An aging population – combined
with a growing number of chronic conditions and shrinking pool of qualified caregivers – brings into question how
our “legacy” system of nursing homes and assisted living facilities can adequately support the long-term needs of the
senior population. A number of studies have questioned whether there will be enough facilities in the coming years to
house everyone with a chronic disease; and even if there were, considerable doubt exists whether our system would be
able to support the costs associated with this form of institutional care.
Over the last decade we have seen a wide-range of diversified housing alternatives emerge as consumer preferences
and reimbursement trends have shifted seniors away from the traditional nursing home. There will be continuing need
for nursing home and assisted living facilities, but these are increasingly a distant second choice to staying at home
among seniors and their loved ones. According to the AARP, more than 90 percent of seniors want to stay in their own
homes as they age into retirement, creating significant demand for technologies and services that facilitate independent
living. In response to these strong preferences, single family homes can now be equipped with remote monitoring
devices and related services to help family members and care providers monitor seniors from afar. Companies like
MedCottage have gone so far as to create portable, high-tech modular homes for senior family members that can be
installed in the backyard of their adult children.
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Another approach is demonstrated by community-based organizations like Beacon Hill Village in Boston, which have
emerged as models for aging-in-place, allowing seniors to live independently with the help of a coordinated team of
volunteers that serve as advocates and assist with everyday tasks such as meals, exercise, and transportation. It has
been estimated that at least 50 similar non-profit communities are up and running today, with another 100+ being
planned across the U.S. These annual fee-based programs tend to attract mid- to upper-income individuals, calling into
question whether this model can work economically across a broader set of geographies. Accordingly, a number of
organizations are exploring variations such as co-housing and intergenerational communities.
We expect these home-based support alternatives to take on a more central role in the care delivery continuum.
However, as more seniors stay in their home we will be faced with new challenges in efficiently delivering care to a
larger and more geographically dispersed population. The sheer number of seniors necessitates an expanded use of
nurses and other care professionals as “force multipliers” to coordinate and direct care across a range of care settings.
Nurse-driven models of care have become much more widespread as organizations look to increase access while
In addition, older persons will inevitably have physical limitations that impact their ability to travel between physician
offices and other care facilities. Telehealth1 and other home-based services will become critical components to serving
the needs of seniors with mobility issues or those in rural communities. All are evidence that innovative efforts that
provide technologies and services to overcome these challenges and better coordinate care across an expanding care
delivery system are underway in many forms.
1 See Exhibit #4 on page 16.
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Integrating Care and Changing Approaches to Care Delivery
Care delivery models designed around holistic approaches to the individual are increasingly viewed as offering better
long-term outcomes as well as lower costs. There are national and international models that have shown promising
results relative to maintaining individual health with a relatively lower cost structure. One approach has featured
organized medical groups that form the basis for all care and related health decisions. Well established examples
include the Kaiser Health System in California, Group Health of Puget Sound in Washington state, various multispecialty medical groups in southern California (operating under capitation payment arrangements for enrollees in
Medicare risk plans), and many smaller medical group-centered Medicare Advantage (MA) plans.
H E A LT H S P R I N G :
C O O R D I N AT E D C A R E F O R M E D I C A R E A D VA N TA G E
HealthSpring [HS] works with primary care medical groups
to facilitate coordinated care and holistic patient management
for seniors enrolled under Medicare Advantage (MA). The
company provides tools and support that promotes data
collection and sharing, accountability to care and outcome
measures, and attention to the patient’s comprehensive
health. Now working with discrete medical groups in 14
sites across many states, data provided by the company
points to positive outcomes, improved patient experience,
enhanced efficiency in medical group operations, and lower
The ability of such programs to manage care in a comprehensive manner has been based on an integrated model
featuring a diversity of professional care providers with a primary care focus. It demands internal communication
between providers and their staff, tools and services to direct and coordinate all levels of care, and a mindset that the
objective is care for the individual through all stages of their life rather than at episodes of acute illness.
With this as a backdrop, efforts to move to wider availability of comprehensive health approaches were advanced by
the medical home and accountable care organization (ACO) initiatives of the Federal government in 2009. Spurred by
legislative support and a significant economic push in the form of government subsidies, an entirely new economy has
exploded in response to the needs of such potential care delivery systems. Nowhere is this approach of more value
than in dealing with the needs of an expanding and often chronically-ill population of older Americans.
A significant component of the work to operationalize and optimize medical homes and accountable care organizations
– each functioning as vertically and horizontally integrated entities that deliver health and wellness services while
being at risk for the costs and outcomes of those services – involves technology-based products, services and support.
These range from the use of technology to extend the care provided by physicians and others to new and innovative
approaches for data collection, analysis and application in actual care decisions and interventions. Each of these is
currently the focus of a number of different development efforts by companies with a variety of backgrounds and skill
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Data to Help Coordinate Care and Enhance Care Delivery
One of the fundamental challenges for the senior population has been the lack of real-time, actionable patient
information that can help the care provider monitor patient status, and in turn, optimize care. Physicians are generally
limited to the intermittent, episodic assessments and observations that are captured during an increasingly short office
visit – one that is typically in response to a short-term problem. When data is available, it is most frequently collected
by health plans, insurers and other fiscal intermediaries who rely on administrative claims data (related to benefit
administration and provider reimbursement) and/or telephonic encounter documentation that is captured during medical
or case management discussions. This data infrequently makes its way to the doctor and only retrospectively when it
does. Instead, it is used by the third party in their own efforts to help “manage” the illness, facilitate other programs or
respond to other needs.
These data points are merely snapshots and typically do not provide a complete longitudinal view of the individual’s
clinical condition, nor are they presented on a real-time basis in order to be actionable at the point of care.
Furthermore, these data points do not offer contextual insight into other non-clinical factors – such as emotional,
environmental, financial, and socio-economic information – that can be equally important to an individual’s overall
Recognizing the situation (and resultant opportunity), innovative companies are responding to these needs with care
management services that hope to shift the healthcare system toward a more patient-centric model of care.
Unlocking Actionable Patient Data in the Home
An accurate, 360° view of the patient requires assessing and monitoring the well-being of patients where they reside
– whether in the home, nursing home, or assisted living facility. Unlike historical claims data which can lag by as
much as 90 to 180 days, live visits and digital technologies can provide near-time or real-time data. This patient-level
intelligence can then be used to identify gaps in care and route appropriate notifications to care providers to ensure the
right level of care is provided at the right place and time.
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M AT R I X M E D I C A L :
PROSPECTIVE IN HOME ASSESSMENTS
Matrix Medical provides prospective medical assessments
and care optimization services to Medicare Advantage
plans and risk-bearing provider groups.
uses a dedicated network of Nurse Practitioners to perform
in-home medical assessments to capture extensive, realtime clinical data that identifies prevalent risk factors and
In this regard, prospective medical assessments (PMA) in the home are increasingly used as a way to enhance clinical
understanding and to facilitate better patient care. In-home medical assessments initially gained traction in the
Medicare Advantage population as an opportunity for payers to ensure accurate documentation of co-morbid conditions
for purposes of risk-adjusted reimbursement. Today, however, innovative service providers are increasingly leveraging
this unique one-on-one interaction in the home to capture real-time patient data that can be used to better coordinate
care. Assessment data can help identify intervention opportunities that would otherwise go undetected in historical
claims/encounter data, and may also create opportunities to assess complementary factors that affect the patient’s
well-being that are generally never found in the typical medical chart (for example, an environmental assessment of the
home to gauge fall risk).
conditions (i.e., prescription medication use problems,
changing physical state, depression indicators). The Matrix
staff work hand-in-hand with primary care physicians and
E X H I B I T # 1 : M edical A ssessments C reate U nique D ata S et to O ptimi z e C are
case management staff to identify gaps in care and route
information/notifications to the most appropriate party to
facilitate interventions in a timely manner. Different from
retrospective risk adjustment efforts (i.e., “medical chart
audits”), the Matrix assessment programs are designed
Historical Data Feeds
Actionable Data Acquired in
the Medical Home
(Retrospective data traditionallly available
to payers via patient chart and claims)
(Additional standard elements captured
in a prospective home assessment)
and clinically validated to identify opportunities to improve
member care and well-being. (At the same time, they may
provide prospective information for recording clinical codes
that are necessary for revenue integrity purposes.)
Financial and Social
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X L H ealth :
M ember surveillance promoting enhanced
chronic care management
XL Health operates under the mandate of Medicare with a
specific design for individuals with chronic conditions such
as diabetes or heart failure (often referred to as a Chronic
Several similar approaches to the in-home assessment of individuals – both for enhancing clinical interventions
and avoiding risk and unforeseen issues (as well as recording mandatory technical data for patient tracking, benefit
administration and reimbursement purposes) – have been introduced to serve seniors living in their own homes. All
include initial direct patient interviews and assessment by specifically trained nurses, the use of specialized electronic
medical records, sophisticated data analysis that becomes part of the creation and sharing of a patient care plan, and
transfer of that information to relevant physicians and caregivers for action.2
Special Needs Plan or C-SNP). The Company has taken
an innovative approach to chronic care management by
Getting a Handle on Complex, Chronic Conditions
developing customized care coordination programs, along
As we develop new strategies for senior care, it makes sense to focus first on the segment of the population that
accounts for the vast majority of overall healthcare spend. It is well known that chronic conditions drive a wildly
disproportionate share of costs across all demographics, with more than 84 percent of our total healthcare dollars
consumed by persons with one or more chronic disease. This becomes even more pronounced in the Medicare
population, with more than 99 percent of all Medicare expenditures associated with members who have one or more
chronic condition (as outlined in Exhibit #2). As a result, any successful effort to moderate the cost of health care is
highly dependent on effectively managing chronic and/or multiple conditions in this segment of the population.
with data management and analytics tools, to identify risk
factors, anticipate health-related problems and look for
A key differentiator for XL Health is their ability to capture
and analyze member data through continuous member touch
points – including in-home medical assessments and 24x7
remote patient monitoring.
These continuous data feeds
enable XL Health to effectively serve as a “surveillance”
company, using real-time patient data to detect early warning
exhibit # 2 :
P ercentage of M edicare E xpenditures
0 Chronic 1 Chronic
signals and proactively intervene before complications spiral
out of control. The company’s nurse and physician staff are
armed on a daily basis with the most recent and relevant
patient specific data (provided through offshore human
capital that allows for 24-hour shifts dealing with data
collection, analysis and transfer) to help them coordinate
care on an individual basis.
Source: Medicare Standard Analytic File, 2007
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2 Services of this type were originally developed to help provide care interventions on a when-needed basis for seniors in nursing homes and assisted
living centers. EverCare, a division of UnitedHealthGroup (NYSE: UNH) was at the forefront of these efforts, and was able to help generate legislative
change at the Federal level which ultimately moved such services from demonstration projects to more widely employed services. This approach to care
is now more widespread, and has attracted significant attention as an approach to enhancing the health of seniors. Companies such as XL Health and
Senior Whole Health – are now serving tens of thousands of seniors in multiple markets. It is likely that they will be joined by others as the number of
seniors coping with chronic illness increases, and gains in health outcomes and care intervention efficiency are documented.
H ealthcare services for aging veterans
As the generation of Vietnam War veterans enter its senior
years, it is developing the same chronic conditions as the
rest of the aging population. However, due to exposure to
Agent Orange and other wartime hazards, Vietnam veterans
are developing these conditions at a higher rate than the
general population. Because many of these conditions are
presumed to be connected to the veterans’ military service,
these veterans are enrolling in the VA healthcare system
to take advantage of free or low-cost healthcare, along
with applying to receive other VA benefits. This increasing
demand for services is taxing the VA health and benefit
systems, creating an enormous backlog. QTC, as the largest
provider of outsourced disability evaluations to the VA, is
assisting the VA to reduce this backlog and respond to the
needs of America’s heroes.
S enior B ridge :
Individual condition management, with care plans designed and delivered in “silos,” rarely improve outcomes and run
the risk of adverse medication reactions, duplicative testing, and conflicting messages to patients and their families.
Appropriate care delivery requires a more comprehensive and coordinated view of the individual. Proactive and
continuous chronic illness management, with resources and care plans designed to balance the risks and benefits
across the complexity of each patient’s condition, offers the best opportunity for preventing and slowing disease
progression and optimizing outcomes. Accomplishing this for individual patients is at the crux of clinical medicine.
Integrated chronic illness management across large populations of seniors requires sophisticated technologies tightly
orchestrated with health management services across the continuum of care for all illness conditions.
New approaches to improving outcomes for people with complex, chronic conditions through the combination of data
assets, analytics, and technology-enabled service models are gaining traction in the market. For example, Special
Needs Plans (SNPs) have adopted a more coordinated approach for patients within certain demographics, like
institutionalized beneficiaries in a long-term care setting, or individuals with severe or disabling chronic conditions
(also referred to as chronic special needs, or (C-SNPs). C-SNPs are designed to provide specialized disease
management and care coordination programs for those with conditions such as diabetes, end-stage renal disease, or
congestive heart failure; in other words, complex chronic disease conditions that are extremely costly to the healthcare
system. These programs have shown the positive impact that proactive care coordination can have on controlling costs
and improving health outcomes.
C omplex chronic care management
SeniorBridge provides home-based care management
programs that are especially beneficial to those with
significant chronic, and often times multiple, medical
Alzheimer’s disease, Parkinson’s disease,
congestive heart failure (CHF) and chronic obstructive
pulmonary disease (COPD) are of particular note in this
The Company’s geriatric care managers lead
coordinated care delivery teams to provide a range of in-home
services customized for the unique needs of each individual.
Unlike most home care service providers, SeniorBridge has,
to date, operated largely under a retail/private pay model,
suggesting a perception among seniors of meaningful value
for the Company’s programs and high-touch service model.
The Company recently began exploring the group market
(via health plan sponsors) as the need for more effective
chronic care management in the home is recognized.
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Enhancing Col laboration Between Payers and Care Providers
access to clinical data :
the axolotl and medicity story
In late 2010, two of the largest pure-play Health Information
Exchange (HIE) platforms (Axolotl and Medicity) were
acquired by large health care insurers/payers, providing
new access to patient-centric clinical data that they
hoped would enable new models of care. These moves by
UnitedHealth Group and Aetna, respectively, helped them
create the necessary infrastructure to merge both clinical
and administrative patient data to identify and close gaps
in care. In turn, they may be closer to having the ability
to support the ACO model by providing the care system
the framework to more effectively take financial risk (e.g.,
capitation) for the comprehensive, fully coordinated care of
individuals and populations.
In an effort to transition to patient-centric models of care, health plans are trying to develop more collaborative
relationships with physicians to lower costs and better manage the overall well-being of patients. These collaborative
efforts attempt to leverage both patient data and local provider networks to improve primary care and identify
opportunities for intervention in advance of high-cost trips to the emergency room and other expensive diagnostics.
This requires a coordinated approach across a range of care providers, with nearly continuous monitoring and shared
communication of events both inside and outside of the physician office.
Innovative payers and health systems are now positioning themselves to provide technology services and data to these
care providers. A number of recent acquisitions (see below) bring into focus an emerging health care provider model
in which payers assume direct control of medical facilities. Such direct ownership (or close contractual relationship)
and oversight of those actually providing care, coupled with the assumption of risk as an insurer, has been successfully
championed by staff model health plans in past years, although performance has been mixed in a number of situations.
Through these transactions, payers are attempting to put themselves in position to access more complete and usable
data, and in turn make it available to providers of care, including those potentially participating in the formation of their
own accountable care organizations.
Already, a number of ACO partnerships and development
D E TA I L S
2,300 physicians in a range of specialities
such as health plans, or simply with the health care system
UnitedHealth / Optum
Applecare Medical Group
200 private practice physicians in Orange County
relying on outside vendors to provide various technology
UnitedHealth / Optum
Memorial Healthcare IPS
400 physicians in Los Angeles
Retail clinics at Wal-Mart in Texas
Sierra Health Services
Nevada clinics acquired in February 2008
38 clinics in Texas and Florida acquired in June 2011
26 clinics in California acquired in June 2011
32 clinics opened in Arizona
540 urgent care and workplace sites acquired in November 20103
West Penn Allegheny Health Systems
Five-hospital networks in Pennsylvania over 4 years starting in June 2011
efforts have emerged. These generally center around large
regional hospital systems, with support from other parties
and administrative services or tools.
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3 The acquisition of Concentra’s 300+ medical centers and 240 work-site facilities demonstrates the renewed convergence of payers and care providers
under the health reform model. While originally focused on workers compensation-related services, Concentra facilities are located in close proximity
to approximately three million Humana members. By taking a broader view of the market space, Humana will be in a position to utilize the clinics and
staff to provide primary medical care for their members and hopefully reduce utilization of outside emergency services, marginal value yet expensive
interventions, various specialists before they may in fact be needed, and preventable institutional care. It also highlights the issues around, and value
of, aligning care providers with benefits administration and the provision of health insurance.
Ta k i n g t h e D e l i v e r y o f C a r e t o t h e P e o p l e
U N I V I TA H E A LT H :
C A R E C O O R D I N AT I O N A N D C O N S U M E R - C E N T R I C
T O O L S E N A B L I N G A G I N G AT H O M E
Univita was launched in 2008 through a series of acquisitions
that included the Long Term Care Group (LTCG), a provider
of long-term care insurance administration services. The
company utilized the LTCG platform to become a broader
care coordination services provider – helping seniors access
care, reside safely in their home and support independent
living. Univita’s care coordination model provides a single
point-of-contact in effect a concierge-type service – for many
of a seniors health care needs. These include skilled nursing
services, home infusion therapies, specialty pharmacy and
durable medical equipment (all or some of which can be
subcontracted rather than owned by Univita itself). This
eliminates the need for third parties (i.e., managed care
plans) to coordinate care with multiple home care providers
and appears to provide faster service, improved care, earlier
inpatient discharges, and fewer readmissions.
Facilitating necessary health care encounters between seniors and care providers is a critical component of a
successful health system. In response to that need, another “back-to-the-future” trend that has emerged is the home
visit by medical professionals. While most patients needing out-patient or non-hospital based care must travel to
provider sites for services, new companies are beginning to change this dynamic by taking care directly to the patient.
This model is particularly advantageous for seniors, who frequently have limited mobility, lack transportation resources,
often forego excursions due to personal inconvenience, and would strongly prefer to receive care in the comfort of their
These approaches are being pursued by companies like WhiteGlove Health (largely selling through self-funded
companies as part of their employee benefit program) and Carena, who have brought back the concept of the “house
call,” and provide an alternative to a trip into the physician’s office. These services, delivered by physicians, nurses,
and nurse practitioners, alleviate potential trips to the pharmacy by providing necessary medications, medical supplies,
and even food and beverages as needed. While this approach may increase costs on some levels (i.e., the cost of the
visit itself), some evidence suggests that bringing the care provider to the patient can result in less in-patient hospital
care and reduce hospital admissions by as much as 10 percent, which may more than offset the increase in cost
associated with sending care professionals into the field. While not currently focused exclusively on seniors, these are
very applicable care delivery models for those with chronic illness.
Other models for this type of “home” based care provide insight to future opportunities to better serve seniors.
Beginning decades ago, the not-for-profit Visiting Nurse Association (VNA), serving as agents of the patient’s physician
and usually focusing on post-hospital care, provided valuable and appreciated outreach to patients at home. Starting
in the late 1980s, EverCare was formed to serve seniors in nursing homes, but later moved to providing customized
at-home services. They employed advanced nurse practitioners, in conjunction with geriatric care physicians, and
special purpose internet-based medical record and communication systems to manage patients. The program has
demonstrated the ability to lower aggregate costs, help realize favorable clinical outcomes and enjoyed tremendous
patient and family satisfaction.
As previously noted, companies such as XL Health, Senior Whole Health, and Univita have emerged to provide similar
home-based and patient-centric services for those in need among the elderly.
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Reimbursement Trends Driving Care Coordination
In the traditional Medicare fee-for-service program, reimbursement is largely structured around the delivery of
services as unique and independent events. In the most extreme analysis, it is a system that pays for illness and fails
to reward prevention and illness avoidance. Fee-for-service participants visit multiple providers who are compensated
independently based on volume, with minimal requirement for interaction or coordination. Ironically, reimbursement is
often available for the most expensive and least desirable care settings (e.g., nursing homes and/or specialized nursing
facilities), yet unavailable for less expensive or preferred settings for seniors, like their home.
Given the enormous funding needs of Medicare, there have been numerous legislative and regulatory efforts to lower
costs and better align reimbursement with clinical outcomes and quality of care. The Medicare Modernization Act
(MMA) of 2003 introduced a complete overhaul of the system, including a number of new incentives for commercial
insurance providers to participate in privatized Medicare plans (i.e., Medicare Advantage). The basic premise of this
initiative was to leverage the private sector’s assumed ability to provide equivalent levels of care at a lower cost, while
also providing seniors with a broader set of services than what is available under traditional Medicare plans.
These expanding coverage options opened up a wide range of business models and expanded set of services to
facilitate senior health. The prevalent model for health plans became one of total risk assumption based on an annually
adjusted capitation payment from the Centers for Medicare and Medicaid Services (CMS). Much of this risk was in turn
passed on to physicians and care providers, often through subsequent capitation structures.
Within this system, however, many believed there was a strong incentive for at-risk care providers and payers to
preferentially seek and enroll the healthiest, and hence least costly seniors. Subsequently, a key catalyst for positive
change became the concept of “risk-adjusted reimbursement,” whereby Medicare Advantage plans are reimbursed
based on the health acuity of their member population. The challenge for payers, who want to ensure the maximum
reimbursement from the government, became the ability to accurately assess the health status of their enrollees. With
doctors having little incentive to record clinical information on a patient beyond the principle reason for appointments, a
void became apparent.
A host of companies emerged (such as MedAssurant and Outcomes) to address this market need, providing clinical
auditing services to identify previously unrecorded co-morbid conditions across the Medicare Advantage population
base. These companies gained traction primarily from a revenue management perspective, ensuring proper
reimbursement across the industry. For example, TripleTree advised The Coding Source in its recapitalization with
Parthenon Capital, which has subsequently become a much broader revenue management platform by combining with
Social Service Coordinators and DCA, Inc.
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As the market has evolved, the concept of risk adjustment has ushered in what some have termed the “second
generation” of Medicare Advantage. Prior to risk adjustment, plans were incented to attract only the healthiest
members; the need for tools and services to manage a broad population of seniors (such as care coordination or
medical management) was perhaps less important since a plan could maximize reimbursement by focusing only on
healthy members. Risk adjustment shifted these incentives and opened up a significant market for technologies and
services that would help plans coordinate care across their member populations. Caring for a diverse population, with
reimbursement appropriate to individuals within that group, became a mandate as well as a goal.
Medicare Advantage plans and SNPs have now expanded their senior initiatives to include remote patient monitoring,
medication therapy management, and several other complementary services to better coordinate care across multiple
care settings. Plans are using third party service providers like Matrix Medical and Censeo to perform prospective
medical assessments, enabling health plans to not only manage revenue, but also to identify intervention opportunities
and better coordinate care through unique touch points in the home. These new coverage alternatives have provided the
framework to more effectively leverage technologies and services that enable aging-in-place.
E X H I B I T # 3 : S enior coverage alternatives
Medicare Fee-For-Service (”FFS”)
Medicare Advantage (MA)
1st Generation (Pre-Risk Adjustment)
Privatized Medicare intended to provide
equivalent levels of care at lower cost;
lacked financial incentives to effectively
Medicaid / “Dual Eligibles”
2nd Generation (Post-Risk Adjustment)
Evolved framework provides incentives to
leverage technologies and services that
facilitate “aging in place” (in home
assessments, remote patient monitoring, etc).
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Te c h n o l o g y a s a Ve h i c l e f o r H e a l t h A s s e s s m e n t a n d C a r e D e l i v e r y
A variety of technology applications have the potential to facilitate improved care and to provide greater access to care
itself. Properly deployed, technology can and should become a force multiplier to enable efficiencies for all types of
care. The potential for savings, both for individuals and the care system overall, is real. It is now time for proof of
concept, and perhaps no population segment is a better target for such services than seniors – those with recurring
medical needs, complex chronic illness, compromised mobility, and limited or tight financial resources.
Of particular note in this area of health care is the ability of certain technologies to serve as “physician extenders”
through both direct and indirect means. One such application is popularly termed “telehealth.” This area commands
great interest among technology companies and similar interest parties, and involves all manner of remote medical
devices that can be used to monitor a senior’s activity and health. Datamonitor estimated that in 2009, telehealth
technology and related services comprised a market well in excess of $3 billion.
Historically, the term telehealth has described the use of information and communication services to transmit health
information and/or to deliver health care. However, when we look at the technology universe that enables seniors to
live longer at home, we see activity in the market spanning three main areas:
E X H I B I T # 4 : T elehealth market segments
• Medication Management
Remote Patient Monitoring
Ambient Assisted Living
• Blood Pressure
• Passive Sleep Senors
• GPS Devices
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Incident–Driven Monitoring is the most mature segment today, focused primarily on Personal Emergency Response
(PERS) solutions such as the Philips Lifeline. This market is evolving toward GPS-enabled devices that will do much
more than just respond to a fall in the home (i.e., triggering an alert when a senior wanders away from the home), or
activity sensing elements that can be used to suggest health problems (such as those deployed by HealthSense). Also
included in this sector are the various “Medication Management” solutions, another fairly mature segment, with a
variety of products from Philips, Lifecomm, and wireless providers like Verizon.
Remote Patient Monitoring includes monitoring biometric data like blood pressure, weight, glucose levels, heart rate, all
interactively connected to a provider. Five companies have significant market share today (Philips, Honeywell, Viterion
(Bayer), Bosch, and Cardiocom), but it is certain that others will emerge. This space is undergoing tremendous
development as home care and nursing facility provider organizations begin to integrate these systems into their
care delivery models and look for ways to help control costs. Senior living communities are also beginning to deploy
these services in homes and apartments as an adjunct to their healthy living focus, and a differentiating point in their
It is highly likely that this trend of remote monitoring will accelerate under the ACO rollout now beginning as care
providers start to take on patient risk and thus look for ways to help control costs outside the four walls of a hospital,
avoid costly re-admissions, and stay away from negative comparative performance data (that will be reported and upon
which various payers will make access and reimbursement decisions).
A further application of the telehealth technology is the direct assessment/evaluation of patients using remote visual,
verbal and transmitted data components. Programs such as that of The University of Texas Medical Branch at
Galveston use a central intake center with physicians evaluating patients by utilizing remote monitoring tools (i.e.,
blood pressure cuffs, stethoscope, otoscope, photos and streaming video) provided at distant locations. The approach
has been shown to be highly beneficial in the care of individuals in the Texas penal system and is commercialized
though NuPhysicia. Similar systems have recently been developed and tested by companies such as Intel, Cisco,
and UnitedHealth Group, and piloted in retail spaces by Walmart and others at various commercial business sites and
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A LOOK AHEAD
The demographic shifts confronting our society, combined with the realities of age and illness, demands a highly
responsive, efficient and progressive system of health care services for older Americans. Significant advances in
approach to care delivery and related services, coupled with the use of important and scalable technology applications,
provide us with necessary tools to implement desired programs and realize results.
Over the next several years we will see important approaches to meeting the health needs of seniors in this country,
including six major trends:
Cohesive, interactive, efficient and provider-centric care will be sought to better address the entire spectrum of an
2. Meaningful changes in reimbursement services will be slow, but progressively change. There will be a shift from
“pay for doing something” to a more global, fully inclusive fee approach that encompasses the entirety of care for
3. The prevention of illness and enhancement of overall well-being will be an increasing focus for all parties.
4. The management, delivery and assessment of medical care will increasingly rely on technology – whether through
improving administrative functions, facilitating data collection and information sharing, providing remote illness
assessment and monitoring, or serving as a vehicle for personal education and support.
5. Aging “in place,” even when confronting personal illness and disability, will increasingly be the preferred choice of
seniors. Economic realities – both individual and societal – will support this trend.
6. A more consumer-responsive approach to care, as well as illness prevention, will emerge as health and wellness
interventions are progressively provided in the home environment.
Innovations in care and support are at hand, and we fully expect their on-going and increasing use to be coupled with
clear advancements in the health of our society.
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